page 1
First Aid Express 2016 workbook: NEUROLOGY
Neurology
How to Use the Workbook with the Videos
Using this table as a guide, read the Facts in First Aid for the USMLE Step 1 2016,
watch the corresponding First Aid Express 2016 videos, and then answer the workbook
questions.
Facts in First Aid for
the USMLE Step 1 2016
Corresponding First Aid
Express 2015 videos
Workbook
questions
450.1–452.2
Embryology (2 videos)
1–3
453.1–482.1
Anatomy & Physiology (12 videos)
4–38
482.2–490.1
Ophthalmology (3 videos)
39–43
491.1–498.1
Pathology (6 videos)
44–48
498.2–505.6
Pharmacology (4 videos)
49–52
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Questions
EMBRYOLOGY
1.
What maternal disease is associated with anencephaly? (p 451) ___________________________
2.
What are the sensory abnormalities in syringomyelia? (p 452) ____________________________
______________________________________________________________________________
3.
Which branchial arches form the posterior 1/3 of the tongue? (p 452) ______________________
ANATOMY AND PHYSIOLOGY
4.
Match the cell type with its characteristic. (p 453)
_____ A. Astrocytes
_____ B. Microglia
_____ C. Neurons
_____ D. Schwann cells
5.
1.
2.
3.
4.
Undergo Wallerian degeneration
Affected in an acoustic neuroma
Form multinucleated giant cells
Maintain blood-brain barrier
_____________(Oligodendroglia/Schwann cells) are destroyed in Gullain-Barré syndrome;
_____________(oligodendroglia/Schwann cells) are destroyed in multiple sclerosis. (pp 453-454)
6.
Match the disease with its alteration in the neurotransmitter. (p 455)
_____ A. Alzheimer disease
_____ B. Anxiety
_____ C. Depression
_____ D. Huntington disease
7.
1.
2.
3.
4.
Decrease in acetylcholine
Decrease in dopamine
Increase in dopamine
Increase in norepinephrine
Which substances cross the blood-brain barrier quickly? Which substances cross it slowly? (p 455)
______________________________________________________________________________
______________________________________________________________________________
8.
Match the area of the hypothalamus with its function. (p 456)
_____ A. Anterior hypothalamus
_____ B. Lateral area
_____ C. Paraventricular nucleus
_____ D. Posterior hypothalamus
_____ E. Suprachiasmatic nucleus
_____ F. Supraoptic nucleus
_____ G. Ventromedial area
1.
2.
3.
4.
5.
6.
7.
Circadian rhythm
Cooling
Heating
Hunger
Makes ADH
Makes oxytocin
Satiety
9.
Ascending sensory information from the body reaches the __________ (VPL/VPM) of the
thalamus, and sensory information from the face reaches the ____________ (VPL/VPM). (p 458)
10.
Decreases in the activity of tuberoinfundibular pathway lead to increases in what secretory protein?
(p 458) ________________________________________________________________________
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11.
In the basal ganglia, the direct pathway utilizes the ____ (D1/D2) receptor and __________
(facilitates/inhibits) movement. The indirect pathway utilizes the ___ (D1/D2) receptor and
____________ (facilitates/inhibits) movement. (p 460)
12.
How does loss of dopamine in Parkinson disease affect the excitatory pathway? How does it affect
the inhibitory pathway? (p 460) ____________________________________________________
______________________________________________________________________________
13.
What are the cardinal features of Parkinson disease? (p 461) _____________________________
______________________________________________________________________________
14.
Which nucleus is affected in Parkinson disease? In hemiballismus? In Huntington disease?
(p 461) ________________________________________________________________________
15.
Define the following terms. (p 461)
A.
Athetosis __________________________________________________________________
B.
Chorea ___________________________________________________________________
C.
Dystonia __________________________________________________________________
D.
Myoclonus ________________________________________________________________
16.
Fluent aphasia with impaired comprehension describes __________ (Broca/Wernicke) aphasia,
whereas nonfluent aphasia with intact comprehension describes __________ (Broca/Wernicke)
aphasia. (p 463)
17.
Match the area of a brain lesion with its clinical effect(s). (p 464)
_____ A. Anterograde amnesia
_____ B. Contralateral hemiballismus
_____ C. Deficits in concentration, orientation, and judgment
_____ D. Eyes look away from side of lesion
_____ E. Eyes look toward side of lesion
_____ F. Intention tremor and limb ataxia
_____ G. Klüver-Bucy syndrome
_____ H. Reduced levels of arousal and wakefulness
_____ I. Hemispatial neglect syndrome
_____ J. Tremor at rest, chorea, or athetosis
_____ K. Truncal ataxia and dysarthria
_____ L. Wernicke-Korsakoff syndrome
_____M. Agraphia, acalculia, finger agnosia, left-right
disorientation
18.
1.Amygdala
2.Basal ganglia
3.Cerebellar hemisphere
4.Cerebellar vermis
5.Frontal eye fields
6.Frontal lobe
7.Hippocampus
8.Mamillary bodies
9.PPRF
10.Dominant parietal cortex
11.Nondominant parietal cortex
12.Subthalamic nucleus
13. Midbrain
What is the major vascular territory covered by the ACA? MCA? PCA? (pp 465-466) __________
______________________________________________________________________________
______________________________________________________________________________
19.
What regulates cerebral perfusion?(p 465) ____________________________________________
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20.
Lesions in PICA or AICA may result in vomiting, vertigo, nystagmus and ipsilateral Horner
syndrome. The two can be distinguished because _________ (AICA/PICA) lesions cause loss of
pain and temperature in the face and limbs, whereas _________ (AICA/PICA) lesions cause
paralysis of the face and pain/temperature loss in the face only. ________ (AICA/PICA) lesions
cause decreased corneal reflex, whereas _______ (AICA/PICA) lesions cause loss of gag reflex,
as well as dysphagia and hoarseness. (p 467)
21.
On CT, an epidural hematoma _______________ (does/does not) cross suture lines, but a
subdural hematoma _______________ (does/does not) cross suture lines. (p 469)
22.
A 50-year-old woman presents to the emergency department with a headache and numbness on
the right side. Her speech is difficult to understand, and her mouth droops when talking.
Noncontrast CT of the head shows bright areas. Should tPA be administered? Why or why not? (pp
469-470) )______________________________________________________________________
23.
What are risk factors for development of idiopathic intracranial hypertension (pseudotumor
cerebri)? (p 471) _______________________________________________________________
_____________________________________________________________________________
24.
What are the symptoms of normal pressure hydrocephalus? (p 471) _______________________
______________________________________________________________________________
25.
Which spinal nerves exit the intervertebral foramina above the corresponding vertebra? Which
spinal nerves exit the foramina below the corresponding vertebra? (p 472) ___________________
______________________________________________________________________________
26.
At what spinal level is a lumbar puncture usually performed? (p 472) ________________________
27.
Using the following chart, compare and contrast the characteristics of upper and lower motor
neuron lesions. (p 473)
Characteristic
UMN Lesion
LMN Lesion
Atrophy
Babinski reflex
Clasp knife spasticity
Fasciculation
Reflexes
Spastic paralysis
Tone
Weakness
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28.
For each lesion in the images below, identify the motor deficit and associated disease(s). (p 474)
A.
B.
D.
E.
C.
F.
G.
A. ____________________________________________________________________________
B. ____________________________________________________________________________
C. ____________________________________________________________________________
D. ____________________________________________________________________________
E. ____________________________________________________________________________
F. ____________________________________________________________________________
G. ____________________________________________________________________________
29.
Match these commonly tested reflexes to their nerve roots: (p 476)
_____ A. Biceps
1. L4
_____ B. Patella
2. C5
_____ C. Triceps
3. S1
_____ D. Achilles
4. C7
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30.
What structures pass through the superior orbital fissure? (p 478) __________________________
31.
Fill in the following chart describing the cranial nerves. (p 479)
CN
I
II
Name
Olfactory
Optic
III
Oculomotor
IV
Trochlear
V
Trigeminal
VI
Abducens
VII
Facial
VIII
Vestibulocochlear
IX
Glossopharyngeal
X
Vagus
XI
Accessory
XII
Hypoglossal
Function
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Type (Sensory/
Motor/Both)
Location in
Brainstem
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32.
Which CNs mediate the pupillary response? (p 479) ____________________________________
33.
If there is a lesion in CNs V and VII, which reflex is impaired? (p 479) _______________________
34.
Which CNs mediate the gag reflex? (p 479) ___________________________________________
35.
With a lesion in CN X, the uvula deviates _______________ (toward/away from) the side of the
lesion. (p 480)
36.
With a lesion in CN XI, the head turns ________ (toward/away from) the side of the lesion. (p 480)
37.
With a lesion in CN XII, the tongue deviates _______________ (toward/away from) the side of the
lesion. (p 480)
38.
What structures pass through the cavernous sinus? (p 481) ______________________________
______________________________________________________________________________
OPHTHALMOLOGY
39.
Where is the obstruction in open/wide angle glaucoma? Where is the obstruction in closed/narrow
angle glaucoma? Which one is painful? (p 484)________________________________________
______________________________________________________________________________
______________________________________________________________________________
40.
Horner syndrome is associated with which three symptoms? (p 487) _______________________
______________________________________________________________________________
41.
Referring to the image, which cranial nerve and muscle are tested with each movement? (p 488)
Line A-B: _______________________________________________________________
Line C-D: _______________________________________________________________
Line E-F: _______________________________________________________________
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42.
Identify the type of visual field defects in the image. (p 489)
43.
Horizontal diplopia develops in a 26-year-old woman with multiple sclerosis. Examination reveals
she cannot adduct her left eye past midline and has a left-beating nystagmus in her right eye when
looking to the right. However, her left eye can adduct during convergence. Where is the lesion most
likely located? (p 490) ____________________________________________________________
______________________________________________________________________________
PATHOLOGY
44.
Match the type of dementia with its defining characteristic. (p 491)
_____ A. Alzheimer disease
_____ B. Creutzfeldt-Jakob disease
_____ C. Frontotemporal dementia
_____ D. Lewy body dementia
45.
1.
2.
3.
4.
α-Synuclein defect
Neurofibrillary tangles
Prions
Tau protein
For each case, identify the type of seizure and its first-line treatment. (pp 494 and 500)
A.
A teenage boy suddenly stiffens, falls down, and experiences rhythmic jerking of his
extremities lasting 1 minute. ___________________________________________________
B.
A 7-year-old boy is referred to his primary physician for “behavioral problems” at school. He
“spaces out” during class. EEG shows a 3-Hz spike-and-wave pattern. __________________
__________________________________________________________________________
C.
A 1-year-old girl is brought to the emergency department because she had been shaking and
unresponsive for 30 seconds. Her rectal temperature is 104ºF. ________________________
D.
A 45-year-old man who suffered a concussion from a car accident has episodes of jerky
movements of his left arm that he cannot control. He remembers the incident itself, but had
blacked out afterward. ________________________________________________________
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46.
What are the main symptoms of a migraine? What mnemonic can you use to remember them?
(p494) ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
47.
48.
For each case, identify the most likely neurocutaneous disorder. (p 495)
A.
A 6-month-old presents with her first seizure. Wood’s lamp examination shows several areas
of hypopigmentation over her trunk and extremities. ________________________________
B.
A 6-month-old has a port wine stain over his left eye and cheek, extending to the tip of his
nose, with a sharp drop-off to normal-toned skin on the right side of his face. _____________
C.
A 6-month-old has congestive heart failure. Imaging shows a cavernous hemangioma in the
liver. ______________________________________________________________________
D.
A 6-month-old has multiple hyperpigmented brown macules scattered over the trunk and upper extremities. _____________________________________________________________
For each case, identify the most likely brain tumor. (pp 496-497)
A.
A 49-year-old man presents with a 2-month history of morning headaches. CT of the head
shows a heterogeneous-appearing mass with irregular borders crossing the corpus callosum.
__________________________________________________________________________
B.
A 40-year-old woman develops a small, well-circumscribed nodular-appearing lesion on her
right frontal lobe. It appears to be attached to the skull. ______________________________
C.
A 4-year-old boy presents with a 1-month history of morning headaches, abnormal gait, and
dysmetria. Imaging shows an appearance in the posterior fossa. ______________________
D.
A 7-year-old girl presents with bitemporal hemianopia. ______________________________
E.
A 36-year-old woman presents with amenorrhea and “problems with peripheral vision” _____
___________________________________________________________________________
PHARMACOLOGY
49.
Match the drug with its indication for use. (pp 498-505)
_____ A. Acute status epilepticus
_____ B. Absence seizures
_____ C. Chronic pain
_____ D. Closed- / narrow-angle glaucoma
_____ E. Induction of anesthesia
_____ F. Insomnia
_____ G. Opiate dependency
_____ H. Seizure prophylaxis in pregnancy
50.
1.
2.
3.
4.
5.
6.
7.
8.
Diazepam
Ethosuximide
Methadone
Phenobarbital
Pilocarpine
Thiopental
Tramadol
Zolpidem
Anesthetics with low blood and lipid solubility have __________ (fast/slow) induction, whereas
anesthetics with high blood and lipid solubility have __________ (fast/slow) induction. (p 502)
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51.
First Aid Express 2016 workbook: NEUROLOGY
What are the two clinical uses of dantrolene? (p 503) _______________________________
______________________________________________________________________________
52.
Describe the mechanism of action for each drug commonly used to treat Parkinson disease.
(pp 504-505)
A.
Benztropine ________________________________________________________________
B.
Bromocriptine ______________________________________________________________
C.
L-dopa
D.
Selegiline __________________________________________________________________
(levodopa)/carbidopa __________________________________________________
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Answers
EMBRYOLOGY
1.
Maternal diabetes (type 1).
2.
“Cape-like” bilateral loss of pain and temperature sensation in upper extremities while fine touch is
preserved.
3.
The 3rd and 4th branchial arches.
ANATOMY AND PHYSIOLOGY
4.
A-4, B-3, C-1, D-2.
5.
Schwann cells; oligodendroglia.
6.
A-1, B-4, C-2 D-3.
7.
Nonpolar/lipid-soluble substances cross rapidly (via diffusion); glucose and amino acids cross
slowly (by carrier-mediated transport).
8.
A-2, B-4, C-6, D-3, E-1, F-5, G-7.
9.
Body-VPL, face-VPM.
10.
Prolactin.
11.
D1, facilitates, D2, inhibits.
12.
Loss of dopamine inhibits the excitatory pathway and disinhibits (or excites) the inhibitory pathway.
13.
Remember TRAPS: Tremor at rest, cogwheel Rigidity, Akinesia, Postural instability, Shuffling gait.
14.
Substantia nigra; caudate nucleus; subthalamic nucleus.
15.
A.
B.
C.
D.
16.
Wernicke; Broca.
17.
A-7, B-12, C-6, D-9, E-5, F-3, G-1, H-13, I-11, J-2, K-4, L-8, M-10.
18.
The ACA supplies the medial surface of the brain, which covers the leg area of the motor and
sensory cortices. The MCA supplies the motor and sensory cortex of the face and arm. The PCA
supplies the occipital cortex.
19.
pCO2
Athetosis: Slow, writhing movements.
Chorea: Sudden, jerky, purposeless movements.
Dystonis: Sustained, involuntary muscle contractions.
Myoclonus: Sudden, brief muscle contractions.
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20.
PICA; AICA; AICA; PICA.
21.
Does not; does.
22.
This patient has had a stroke, and the bright areas on noncontrast CT indicate hemorrhage. Thus
tPA should not be administered.
23.
Risk factors for idiopathic intracranial hypertension (ICH) include being a woman of childbearing
age, having excess Vitamin A, and the use of danazol.
24.
Ataxia, dementia, and urinary incontinence.
25.
Nerves C1-C7 exit above the corresponding vertebra; the others exit below the corresponding
vertebrae.
26.
In the L3-L4 or L4-L5 interspace.
27.
Characteristic
28.
UMN Lesion
LMN Lesion
Atrophy
–
+
Babinski reflex
+
–
Clasp knife spasticity
+
–
Fasciculation
–
+
Reflexes
Spastic paralysis
↑
+
↓
–
Tone
↑
↓
Weakness
+
+
A.
Lower motor neuron lesions only, attributable to destruction of anterior horns; poliomyelitis
and Werding-Hoffmann disease.
B.
Random and asymmetric lesions due to demyelination; multiple sclerosis.
C.
Combination of upper and lower motor neuron deficits with no sensory deficit; amyotrophic
lateral sclerosis.
D.
Complete occlusion of anterior spinal artery with sparing of dorsal columns and tract of
Lissauer.
E.
Degeneration of dorsal roots and dorsal columns; tabes dorsalis.
F.
Damage to the crossing fibers of the corticospinal tract; syringomyelia.
G.
Demyelination of dorsal columns, lateral corticospinal tracts, and spinocerebellar tracts;
vitamin B12 neuropathy, vitamin E deficiency, and Friedrich ataxia.
29.
A-2, B-1, C-4, D-3.
30.
CN III, CN IV, CN V1, CN VI, ophthalmic vein, sympathetic fibers.
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31.
CN
I
II
Name
Olfactory
Optic
Function
Smell
Sight
III
Oculomotor
Extraocular eye
movements
Pupillary constriction
Eyelid opening
IV
Trochlear
V
Trigeminal
VI
Abducens
Extraocular eye
movements
Facial sensation
Muscles of mastication
Extraocular eye
movements
Type (Sensory/
Motor/Both)
Sensory
Sensory
Location in
Brainstem
In cerebrum
Midbrain
Motor
Midbrain
Motor
Midbrain
Both
Pons
Motor
Pons
Both
Pons
VII
Facial
Muscles of facial
expression
Taste from anterior two
thirds of tongue
Lacrimation, salivation
Eyelid closing
Stapedius muscle in ear
VIII
Vestibulocochlear
Hearing, balance
Sensory
Pons
Glossopharyngeal
Taste from posterior third
of tongue
Swallowing, palate
elevation
Salivation
Chemo- and
baroreceptors of the
carotid body and sinus
Both
Medulla
X
Vagus
Taste from epiglottic
region
Swallowing, palate
elevation
Midline uvula
Muscles of pharynx and
larynx
Parasympathetics to
visceral organs
Aortic arch chemo- and
baroreceptors
Both
Medulla
XI
Accessory
Head turning
Shoulder shrugging
Motor
Medulla
XII
Hypoglossal
Tongue movement
Motor
Medulla
IX
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32.
CNs II and III mediate the papillary response.
33.
The corneal reflex is impaired if a lesion occurs in CNs V and VII.
34.
CNs IX and X mediate the gag reflex.
35.
The uvula deviates away from the side of the CN X lesion.
36.
There is weakness turning the head away from the CN XI lesion.
37.
The tongue deviates toward the side of the CN XII lesion.
38.
CN III, CN IV, CN V1, CN V2, CN VI, sympathetic fibers, internal carotid artery.
OPHTHALMOLOGY
39.
Open/wide angle glaucoma is due to obstructed outflow. Closed/narrow angle glaucoma is due to
obstructed flow between iris and lens. Closed/narrow angle glaucoma is painful.
40.
Ptosis, anhidrosis, miosis.
41.
Line A-B (SR-SO): assesses CN III—all but the superior oblique and the lateral rectus.
Line C-D (IO-IR): assesses CN IV—the superior oblique.
Line E-F (LR-MR): assesses CN VI—the lateral rectus.
42.
43.
Her left eye can adduct during convergence but not during right lateral gaze because the
oculomotor nerve itself works perfectly, but the connection between the abducens nuclei and the
oculomotor nuclei is impeded. The “message” to look right does not reach the left medial rectus,
causing the right eye to beat leftward because of the dysconjugate image. (If you are still confused,
now would be an excellent time to review INO.)
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PATHOLOGY
44.
A-2, B-3, C-4, D-1.
45.
A.
B.
Generalized tonic-clonic (grand mal) seizures. Treat with phenytoin, carbamazepine, or
valproic acid.
Absence seizures. Treat with ethosuximide.
C.
Febrile seizures. Do not use antiepileptics. Give acetaminophen for the fever. If it appears to
be a simple febrile seizure (1 seizure/illness; no previous febrile seizures), recurrence of
seizure is unlikely.
D.
Simple partial seizures with secondary generalization. Virtually any antiepileptic drug can be
used; the most common are phenytoin, carbamazepine, levetiracetam, and valproic acid.
46.
The main symptoms of migraines are unilateral, pulsating pain with nausea, photophobia, or
phonophobia. This pain is usually disruptive to everyday activity. The mnemonic that one can use to
remember these symptoms are POUND (Pulsatile, One-day duration, Unilateral, Nausea,
Disabling).
47.
A.
B.
C.
48.
D.
Tuberous sclerosis.
Sturge-Weber syndrome.
Cavernous hemangiomas can occur in isolation, but are associated with von Hippel-Lindau
disease.
Neurofibromatosis type 1.
A.
B.
C.
D.
E.
Glioblastoma multiforme.
Meningioma.
Medulloblastoma.
Craniopharyngioma.
Prolactinoma (pituitary adenoma)
PHARMACOLOGY
49.
A-1, B-2, C-7, D-5, E-6, F-8, G-3, H-4.
50.
Fast; slow.
51.
Malignant hyperthermia and neuroleptic malignant syndrome.
52.
A.
Inhibits acetylcholine, which preferentially excites the inhibitory pathway over the excitatory
pathway. The net effect of acetylcholine is inhibition of the thalamus.
B.
Dopamine receptor agonist.
C.
Inhibits peripheral breakdown of L-dopa, which crosses the blood-brain barrier and is
converted to dopamine in the brain. The net effect is an increase of dopamine in the brain
milieu.
D.
Inhibits MAO-B enzyme, resulting in less breakdown of dopamine in the CNS.
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